Showing papers in "Southern Medical Journal in 2006"
TL;DR: Although BAS monotherapy effectively lowers LDL-C, combination therapy, especially with BAS and statins, is becoming increasingly common due to complementary mechanisms of action, and it is becoming clear that BAS and other therapies that manipulate the bile acid synthetic pathway may have clinically useful therapeutic effects on other metabolic disorders including type 2 diabetes.
Abstract: Bile acid sequestrants (BAS) continue to command a position in the treatment of dyslipidemias 25 years after their introduction. Partial diversion of the enterohepatic circulation using BAS depletes the endogenous bile acid pool by approximately 40%, thus stimulating an increase in bile acid synthesis from cholesterol, which lowers low-density lipoprotein cholesterol (LDL-C) by 15 to 26%. Three BAS are currently used for treating hypercholesterolemia in the United States: the conventional sequestrants, cholestyramine and colestipol, and the specifically engineered BAS, colesevelam hydrochloride (HCl). Compared with conventional BAS, colesevelam HCl has enhanced specificity, greater affinity, and higher capacity for binding bile acids, due to its polymer structure engineered for bile acid sequestration. BAS are not absorbed by the intestine and thus have no systemic drug-drug interactions, but may interfere with the absorption of some drugs. Although BAS monotherapy effectively lowers LDL-C, combination therapy, especially with BAS and statins, is becoming increasingly common due to complementary mechanisms of action. Low-dose statin plus BAS combinations lead to greater or similar LDL-C reductions compared with high-dose statin monotherapy and may have a better safety profile. Combinations of BAS with nonstatin lipid-lowering agents, including niacin, fibrates, and cholesterol absorption inhibitors, may be useful in those patients who require intensive lipid-lowering, but are statin intolerant. BAS treatment can significantly reduce coronary artery disease (CAD) progression and the risk of CAD-associated outcomes. It is also becoming clear that BAS and other therapies that manipulate the bile acid synthetic pathway may have clinically useful therapeutic effects on other metabolic disorders including type 2 diabetes.
294 citations
TL;DR: Evaluating the accuracy of death certificates in reporting vital statistics with an emphasis on cardiac deaths found major discrepancies of commission and omission occur frequently between the death certificate and autopsy.
Abstract: Background Medicine assumes that vital statistics are accurate, but they are only as good as the death certificates. Objective To evaluate the accuracy of death certificates in reporting vital statistics with an emphasis on cardiac deaths. Design A population-based retrospective study within one community hospital. Patients During the study period, 1,619 patients expired during hospitalization, of which 223 underwent autopsy. Interventions Clinical diagnoses were determined from the death certificate and autopsy results from the final pathology reports. Measurements Concordance of myocardial infarction as the underlying cause of death between the death certificate and the autopsy was measured. New diagnoses uncovered by the autopsy were tabulated. Results The death certificate missed acute myocardial infarction in 25 of 52 autopsy-proven cases (48% errors of omission). Conversely, it erroneously asserted the presence of an acute myocardial infarction in 9/36 cases (25% errors of commission). Autopsy showed these nine cases actually were pneumonia (5), sepsis with ARDS (2), cerebral hemorrhage (1), and cardiac tamponade (1). Autopsy proved 52 myocardial infarctions causing death, while death certificates accurately reported only 27. Myocardial infarction was more likely to be unsuspected in extreme ages, in women, when found in right ventricle or posterior wall, and in the presence of sepsis or ARDS. Death certificates were frequently inaccurate and in 21.5% of cases were of no value because of an inadequate diagnosis, ie, cardiopulmonary arrest, arrhythmia or respiratory failure. Conclusion Major discrepancies of commission and omission occur frequently between the death certificate and autopsy. 1) Death certificates are often wrong. 2) The time-honored autopsy is more valuable than ever. 3) Physicians need to write better death certificates and correct them. 4) Death certificate-based vital statistics should be corrected with autopsy results. 5) Vital statistics should note deaths confirmed by autopsy. 6) More autopsies would improve vital statistics and the practice of medicine.
121 citations
TL;DR: The pathophysiology of hyperglycemia during trauma and surgical stress is reviewed and practical recommendations for the preoperative, intraoperative, and postoperative care of diabetic patients are provided.
Abstract: Patients with diabetes are more likely to undergo surgery than nondiabetics, and maintaining glycemic control in subjects with diabetes can be challenging during the perioperative period. Surgery in diabetic patients is associated with longer hospital stay, higher health care resource utilization, and greater perioperative mortality. In addition, several observational and interventional studies have indicated that hyperglycemia is associated with adverse clinical outcomes in surgical and critically ill patients. This paper reviews the pathophysiology of hyperglycemia during trauma and surgical stress and will provide practical recommendations for the preoperative, intraoperative, and postoperative care of diabetic patients.
112 citations
TL;DR: Clinicians should be aware that OSA may be a risk factor for the development of cardiovascular disease, especially in patients with pre-existing pulmonary disease.
Abstract: Obstructive sleep apnea (OSA) is a common medical condition that occurs in a considerable percentage of the population. Substantial evidence shows that patients with OSA have an increased incidence of hypertension compared with individuals without OSA, and that OSA is a risk factor for the development of hypertension. It is established that OSA may be implicated in stroke and transient ischemic attacks. OSA is associated with coronary heart disease, heart failure, and cardiac arrhythmias. Pulmonary hypertension may be associated with OSA, especially in patients with pre-existing pulmonary disease. Although the exact cause that links OSA with cardiovascular disease is unknown, there is evidence that OSA is associated with a group of proinflammatory and prothrombotic factors that have been identified as important in the development of atherosclerosis. OSA is associated with increased daytime and nocturnal sympathetic activity. Autonomic abnormalities seen in patients with OSA include increased resting heart rate, decreased R-R interval variability, and increased blood pressure variability. Both atherosclerosis and OSA are associated with endothelial dysfunction, increased C-reactive protein, interleukin 6, fibrinogen, plasminogen activator inhibitor, and reduced fibrinolytic activity. OSA has been associated with enhanced platelet activity and aggregation. Leukocyte adhesion and accumulation on endothelial cells are common in both OSA and atherosclerosis. Clinicians should be aware that OSA may be a risk factor for the development of cardiovascular disease.
105 citations
TL;DR: In this review, common etiologies seen in adult patients with thrombocytopenia are highlighted and guidance regarding selection of the appropriate product, indications and contraindications, and suggested target platelet counts for various clinical situations are given.
Abstract: With the widespread use of automated cell counters, clinicians in any field of medicine may encounter thrombocytopenia. The symptomatology may vary greatly and the underlying cause may be either inconsequential (pseudothrombocytopenia) or life threatening. It is important to be aware of common conditions leading to thrombocytopenia and have a systematic approach to evaluation and management of these patients. In this review we highlight common etiologies seen in adult patients with thrombocytopenia. A brief description and management approach to common conditions, as well as to conditions that may be less frequent but require emergent intervention, is provided. Often the clinician is called upon to make a decision about platelet transfusions. The review also discusses the various types of platelet products available for transfusion and gives guidance regarding selection of the appropriate product, indications and contraindications, and suggested target platelet counts for various clinical situations.
96 citations
TL;DR: Risks to workers in a number of new occupations and industries are reviewed and nonoccupational risk factors that are known or at one time have been thought to increase the risk of bladder cancer are discussed.
Abstract: Workplace exposures account for 5 to 25% of all bladder cancer cases. A critical review of the literature between 1938 and 2004 was performed, with a focus on occupational exposures. Occupational exposure to bladder carcinogens, particularly to beta-naphthylamine occur in a number of industries, including aromatic amine manufacture, rubber and cable manufacture, and dyestuff manufacture and use. Risks to workers in a number of new occupations and industries are reviewed. Nonoccupational risk factors that are known or at one time have been thought to increase the risk of bladder cancer are also discussed.
87 citations
TL;DR: It is suggested that topical imiquimod 5% cream–at least 3 times per week (with 1–2 d of nontreatment in between) for a minimum of 8 to 16 weeks—be considered as an initial treatment for primary cutaneous extramammary Paget disease.
Abstract: Extramammary Paget disease is an uncommon cutaneous neoplasm that presents as erythematous plaques most frequently located in the anogenital region. Management of patients with extramammary Paget disease involves evaluation of the individual for: (1) a disease-associated, unsuspected, visceral malignancy and (2) secondary adenocarcinoma in the underlying dermis or regional lymph nodes. Several modalities, each with variable effectiveness, are available to treat the cutaneous component of the disease: electrodesiccation and curettage, laser surgery, aminolevulinic acid photodynamic therapy, radiotherapy, topical chemotherapy, and wide surgical excision. However, surgical excision using the Mohs micrographic technique is currently the modality of choice for treating the cutaneous lesions of extramammary Paget disease. Recently, a topical imidazoquinoline immunomodulator that induces cytokine production and stimulates the innate and cellular immune responses--imiquimod cream-has been used for the management of primary or relapsing extramammary Paget disease. Complete healing, without recurrence, of extramammary Paget disease in patients whose cutaneous lesions were treated topically with imiquimod 5% cream was observed. We describe a man with suprapubic extramammary Paget disease whose condition was primary and limited to his skin. Biopsy-confirmed complete resolution of his disease was observed after the topical application of imiquimod 5% cream 3 times per week (on alternate days) for 16 weeks. After reviewing the published reports of other patients with extramammary Paget disease whose disease was successfully treated with imiquimod cream, we suggest that topical imiquimod 5% cream-at least 3 times per week (with 1-2 d of nontreatment in between) for a minimum of 8 to 16 weeks--be considered as an initial treatment for primary cutaneous extramammary Paget disease. Surgical excision or an alternative therapeutic modality is recommended for patients whose extramammary Paget disease persists or recurs after treatment with topical imiquimod.
87 citations
TL;DR: The management issues for children with CLP/CPA and how these are addressed by members of the MCC are discussed, discussing the many medical issues that these children face are comprehensively addressed in the most convenient manner.
Abstract: Cleft lip with or without a cleft palate (CLP) and cleft palate alone (CPA) are common birth defects, with a combined birth prevalence of about 1 to 2/1,000. 1 Affected children have a number of medical issues and potential complications, and therefore require a wide variety of healthcare specialists beyond plastic surgeons and dental specialists. For this reason, the best environment in which to deliver this care is a multidisciplinary cleft clinic (MCC) that features a team of healthcare providers, including audiology, pediatric otolaryngology, speech pathology, occupational/feeding therapy, and genetics. In this setting, the many medical issues that these children face are comprehensively addressed in the most convenient manner, as all the specialists can be seen in a single busy day. Furthermore, the referring primary care provider (PCP) will receive a concise letter that documents the team evaluation, including future management plans and recommendations for therapy. Unfortunately, few papers are available in the literature that review the workings of these clinics. In this paper we will provide such an overview, discussing the management issues for children with CLP/CPA, and how these are addressed by members of the MCC.
86 citations
TL;DR: It is demonstrated that an inverse relationship exists between hand perfusion and the duration of symptoms of CRPS I and a positive correlation exists between SGB efficacy and how soon SGB therapy is initiated.
Abstract: INTRODUCTION The purpose of this study was to examine the efficacy of stellate ganglion blockade (SGB) in patients with complex regional pain syndromes (CRPS I) of their hands. METHODS After IRB approval and patient informed consent, 25 subjects, with a clinical diagnosis of CRPS I of one hand as defined by the International Association for the Study of Pain (IASP) criteria, had three SGB's performed at weekly intervals. Laser Doppler fluxmetric hand perfusion studies were performed on the normal and CRPS I hands pre- and post-SGB therapy. No patient was included in this study if they used tobacco products or any medication or substance that could affect sympathetic function. The appropriate parametric and nonparametric data analyses were performed and a p value <0.05 was used to reject the null hypothesis. RESULTS Symptom onset of CRPS I until the initiation of SGB therapy ranged between 3 to 34 weeks. Following the SGB series, patient pain relief was as follows: group I, 10/25 (40%) had complete symptom relief; group II, 9/25 (36%) had partial relief and group III, 6/25 (24%) had no relief. The duration of symptoms until SGB therapy was: group I, 4.6 +/- 1.8 weeks, group II, 11.9 +/- 1.6 weeks and group III, 35.8 +/- 27 weeks. Compared with the normal control hand, the skin perfusion in the CRPS I affected hand was greater in group I and decreased in groups II and III. DISCUSSION The results of our study demonstrate that an inverse relationship exists between hand perfusion and the duration of symptoms of CRPS I. On the other hand, a positive correlation exists between SGB efficacy and how soon SGB therapy is initiated. A duration of symptoms greater than 16 weeks before the initial SGB and/or a decrease in skin perfusion of 22% between the normal and affected hands adversely affects the efficacy of SGB therapy.
86 citations
TL;DR: Patients of all literacy levels had limited understanding of OCP side effects and what to do about multiple missed pills, which puts them at risk for misuse.
Abstract: Objective: To assess patient understanding and use of oral contraceptive pills (OCPs) and determine if these are associated with literacy. Methods: Four hundred OCP users from a southern public health family planning clinic were orally tested post visit for literacy, demographics, contraceptive knowledge, OCP use, side effects, and adherence. Results: Patients were predominately African American (86%); 78% had completed high school and 42% read below a 9th grade level. Most (94%) understood what to do when they missed one pill, yet few knew the correct action to take after missing two or three pills (19% and 3% respectively); 33% reported missing one or more pills in the past 2 weeks. Literacy was not associated with OCP use, knowledge, or adherence. Conclusion: Patients of all literacy levels had limited understanding of OCP side effects and what to do about multiple missed pills. This puts them at risk for misuse.
83 citations
TL;DR: Chronic oral-dosed osteoporosis therapies are associated with poor adherence and persistence, regardless of age or dosing regimen, and drug therapies and patient management approaches associated with improved adhere and persistence could improve the likelihood of achieving the therapeutic benefits observed in rigorously controlled clinical trials.
Abstract: Background: The effectiveness of chronic therapies can be compromised by poor adherence and persistence. Materials and Methods: Investigators identified a cotitinuously bcncflt-ciigibic cohort of women from a large, geographically diverse, national managed care plan who were newly diagnosed and treated for osteoporosis with alendronate, risedronate, or raloxifene. Drug titilization parameters were evaluated over a 12-month follow-up period for tbe study population. Adherence was assessed using a medication possession ratio calculated as total days of therapy for medication dispensed/365 days of study follow-up. Persistence was defined as continuous therapy on the satne drug for each month over the entire .study period. Adherence and persistence were also evaluated for all three sttidy agents in wotiien S:65 years of age. Results: In the study cohort (N = 10.566), 12-month adherence/ persistence rates were alendronate 61%/2I%, risedronate 58%/t9%. and ralo.\ifene 54%/16%. Rates in women ^65 years were similar to those in the entire study cohort. Weekly bisphosphonate users had slightly higher 12-month adherence (63% versus 54%, P < 0.05) and persistence (22% versus 19%, P — NS) rates than did daily users, independent of agent. Conclusion: Chronic oral-dosed osteoporosis therapies are associated with poor adherence and persistence, regardless of age or dosing regitnen. Drug therapies and patient management approaches associated with improved adherence and persistenee could improve the likelihood of achieving the therapeutic benefits observed in rigorously controlled clinical trials.
TL;DR: Combining effective education strategies with the needs of physicians at specific points in their education may be effective in reversing the negative trends seen in attitudes toward caring for patients with substance abuse problems.
Abstract: Introduction Physicians in all specialties commonly encounter patients who abuse alcohol or illegal drugs Working with these patient populations can be challenging and potentially engender negative attitudes This study is designed to identify the progression of attitudinal shifts over time of physicians-in-training toward caring for substance abusing patients Methods and materials A 31-item survey was designed to capture demographic information of participants, attitudes toward treating patients with substance abuse diagnoses, previous participant education, experience in and comfort with diagnosing and treating substance abuse, and satisfaction achieved in working with this patient population Medical students in their third and fourth years of education as well as residents in training, years one through four, were surveyed Responses to the survey's attitudinal items were analyzed across years of training, looking for changes associated with time and experience Results Fifty-seven percent of eligible participants anonymously completed the survey There was general agreement across all years of training that health care professionals should be allowed continued employment in their professions when in recovery from alcohol abuse (P = 0424) and drug abuse (P = 0409) Across years of training there was agreement that patients can recuperate and provide meaningful contributions to society when recovering from alcohol (P = 0847) and drug (P = 0859) abuse From medical school years through residency there were enhanced beliefs that alcohol-abusing patients (P = 0027) and drug-abusing patients (P = 0009) overutilize health care resources Most trainees, despite year of education, believe patients who abuse alcohol (P = 0521 and illegal drugs (P = 0356) have challenging medical and social issues from which they can learn There was consistency across years in the perception that providing care to alcohol-abusing patients (P = 0679) and drug-abusing patients (P = 0090) is repetitive and detracts from the care of others All felt their training was adequate to care for alcohol (P = 0628) and drug-abusing patients (P = 0484) Satisfaction achieved in caring for alcohol (P = 0017) and illegal drug-abusing patients (P = 0015) consistently diminishes over years in training Conclusions There are positive as well as negative aspects for physicians-in-training to caring for patients with alcohol and illegal drug abuse problems Combining effective education strategies with the needs of physicians at specific points in their education may be effective in reversing the negative trends seen in attitudes toward caring for patients with substance abuse problems
TL;DR: A case series ofEBV infections with clinically significant hepatitis is presented and the literature on the gastrointestinal complications of EBV is reviewed.
Abstract: Epstein Barr virus (EBV) infection causes asymptomatic liver-associated enzyme abnormalities in 80 to 90% of cases which are often unrecognized. Patients with acute EBV infections may also develop cholestatic hepatitis with associated jaundice and hepatitis with moderate elevations in the transaminase levels. Other gastrointestinal complications associated with EBV may include splenic rupture, liver failure due to acute and/or chronic EBV infection, and perhaps, autoimmune hepatitis and hepatocellular carcinoma. This article presents a case series of EBV infections with clinically significant hepatitis and reviews the literature on the gastrointestinal complications of EBV.
TL;DR: A high proportion of patients entered clinical care after experiencing substantial disease progression, and interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed.
Abstract: Background
Despite the proven benefits conferred by early human immunodeficiency virus (HIV) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States.
TL;DR: Patients who suffered a PICC-associated DVT were more likely to be undergoing treatment for cancer, and the use of prophylactic anticoagulation did not reduce this risk.
Abstract: Background: Peripherally inserted central catheters (PICC) are common venous access devices. Clinical conditions and therapies that increase the risk of PICC-associated thrombosis have not been studied. Methods: We performed a retrospective case-control analysis of all adult patients who underwent placement of a PICC at our hospital over a three-year period (n = 1296). Clinical variables examined were indication for PICC placement, active cancer treatment, history of DVT, diabetes mellitus, and use of prophylactic anticoagulation. Results: The overall incidence of PICC-associated DVT was 2% (n = 27). Active cancer therapy was significantly associated with PICC-associated DVT (OR 3.5, 95% CI 1.3-9.8). The use of prophylactic anticoagulation did not reduce this risk. Conclusions: Patients who suffered a PICC-associated DVT were more likely to be undergoing treatment for cancer. This risk was not lowered by the use of prophylactic anticoagulation. These results suggest a need for prospective studies on effective anticoagulation for patients at high risk for PICC-associated DVT.
TL;DR: A structured goal-directed approach to chronic opioid treatment is suggested; this aims to select and monitor patients carefully, and wean therapy if treatment goals are not reached.
Abstract: This article first reviews the evidence for and against chronic opioid therapy. Evidence supporting the opioid responsiveness of chronic pain, including neuropathic pain, includes multiple randomized trials conducted over months (up to 8 months). Observational studies are conducted for longer, and many also support opioid analgesic efficacy. Concerns have arisen about loss of efficacy with prolonged use, possibly related to tolerance or opioid-induced hyperalgesia. Mechanisms of tolerance and opioid-induced hyperalgesia are explored. Evidence on other important outcomes such as improvement in function and quality of life is mixed, and is less convincing than evidence supporting analgesic efficacy. It is clear from current evidence that many patients abandon chronic opioid therapy because of the unacceptability of side effects. There are also concerns about toxicity, especially when opioids are used in high doses for prolonged periods, related to hormonal and immune function. The issue of addiction during opioid treatment of chronic pain is also explored. Addiction issues present many complex questions that have not been satisfactorily answered. Opioid treatment of pain has been, and remains, severely hampered because of actual and legal constraints related to addiction risk. Pain advocacy has focused on placing addiction risk into context so that addiction fears do not compromise effective treatment of pain. On the other hand, denying addiction risk during opioid treatment of chronic pain has not been helpful in terms of providing physicians with the tools needed for safe chronic opioid therapy. Here, a structured goal-directed approach to chronic opioid treatment is suggested; this aims to select and monitor patients carefully, and wean therapy if treatment goals are not reached. Chronic opioid therapy for pain has not been a universal success since it was re-established during the last two decades of the twentieth century. It is now realized that the therapy is not as effective or as free from addiction risk as was once thought. Knowing this, many ethical dilemmas arise, especially in relation to patients' right to treatment competing with physicians' need to offer the treatment selectively. In the future, we must learn how to select patients for this therapy who are likely to achieve improvement in pain, function and quality of life without interference from addiction. Efforts will also be made in the laboratory to identify opioids with lower abuse potential.
TL;DR: A rib fracture clinical pathway focusing on patients 45 years and older with more than 4 rib fractures is established, hypothesizing that patients as young as age 45 demonstrate increased morbidity with injuries similar to older patients.
Abstract: Background: Recent studies on the impact of rib fractures after blunt trauma have shown a linear relationship between age, increasing number of rib fractures, and complications, including mortality. Others have documented that age-related morbidity increases before age 65 in trauma patients. We hypothesize that patients as young as age 45 demonstrate increased morbidity with injuries similar to older patients. Methods: We performed a retrospective cohort study involving all blunt trauma patients with rib fractures, excluding those with severe head and abdominal injuries and those dying within 24 hours, admitted between January 2001 and December 2004. Outcome parameters included pulmonary complications, ICU length of stay, hospital and ICU length of stay, Injury Severity Score (ISS), number of vent days, number of rib fractures, mechanism of injury, and discharge disposition. Results: Of the 3,094 patients admitted, 307 met the inclusion criteria (9.9%). Based on statistical analysis of age, number of rib fractures, and adverse outcome variables, patients were separated into 4 groups: Group 1: younger than 44 years old with 1 to 4 rib fractures, Group 2: younger than 44 years with greater than 4 rib fractures, Group 3: 45 years or older with 1 to 4 rib fractures, and Group 4: 45 years or older with more than 4 rib fractures. Age groups and outcome variables were compared with chi-square, analysis of variance and multiple regression analysis. Respiratory failure, pneumonia, and associated thoracic injuries were increased in Group 4 patients compared with other groups (P < 0.05). Mortality and length of stay were not different between groups. Conclusions: Patients as young as 45 with more than 4 rib fractures are at increased risk for adverse outcomes. Efforts to improve outcomes in rib fracture patients should focus not only on elderly patients, but on those as young as 45 years. Based on these data, we established a rib fracture clinical pathway focusing on patients 45 years and older with more than 4 rib fractures.
TL;DR: Serum leptin levels were found to be significantly higher in rheumatoid arthritis patients than in control subjects in this study, and there was no correlation between serum leptin levels and TNF-α levels, clinical and laboratory parameters of disease activity.
Abstract: OBJECTIVES This study was performed to evaluate serum leptin levels in rheumatoid arthritis (RA) patients and investigate the correlation with serum tumor necrosis factor alpha (TNF-alpha) levels and clinical and laboratory parameters of disease activity. METHODS Fifty patients with RA and 34 control subjects were included. Disease activity score 28 (DAS28) was calculated for each patient. Laboratory activity was assessed by examining erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Immunoradiometric assay was used for measuring serum leptin levels (ng/mL). Serum TNF-alpha levels (pg/mL) were measured by sandwich enzyme-linked immunosorbent assay method in 41 of 50 RA patients and in 24 control subjects. RESULTS Age, sex and body mass index (BMI) did not show a statistically significant difference between RA and control subjects (P > 0.05). Serum leptin levels were higher in RA (P = 0.000). In RA patients, there were no correlations between serum leptin levels and disease duration, swollen and tender joint counts, DAS28, CRP, ESR, serum TNF-alpha levels, oral glucocorticoid and methotrexate usage (P > 0.05). There was no statistically significant serum leptin level difference between patients with high disease activity and mild and low disease activity (P = 0.892). Serum leptin levels positively correlated with BMI in both patient and control groups (P < 0.05). In both groups, mean serum leptin levels were higher in women than men. CONCLUSIONS Even though serum leptin levels were found to be significantly higher in RA patients than in control subjects in this study, there was no correlation between serum leptin levels and TNF-alpha levels, clinical and laboratory parameters of disease activity. However serum leptin levels positively correlated with BMI in both patient and control groups. In RA, circulating leptin levels do not seem to reflect disease activity.
TL;DR: The scope of this medical response to Hurricane Katrina is described, citing the major challenges, successes, and recommendations for conducting similar efforts in the future.
Abstract: On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility--the Katrina Clinic--at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.
TL;DR: RPA, an aerobic/anaerobic polymicrobial infection, is increasing in frequency and is associated with increased recovery of GABHS in the authors' patients, whether this rise in incidence is due to increased invasiveness ofGABHS strains is to be determined.
Abstract: Background: Because of a recent increase in the number of cases of retropharyngeal abscess (RPA) admitted to our hospital, we reviewed the incidence, microbiology, and treatment outcome of RPA during an 11-year period (1993-2003) Methods: A retrospective review of medical records of children with RPA Results: Sixty-seven children (46 males) with RPA were identified, representing a 45-fold increase in incidence over a previous 12-year period The majority (66%) of patients presented during the last 4 years Computed tomography revealed inflammatory or ring enhancing lesion in all patients Abscess drainage was performed in 51 (76%) patients A total of 101 isolates (84 aerobes, 17 anaerobes) were recovered from 41 specimens (a mean of 25 isolates per specimen) Group A beta hemolytic streptococcus (GABHS) was recovered from 22 (54%) of 41 specimens compared with 6 (35%) of 17 over the previous 12 years Treatment included IV antibiotics: ampicillin/sulbactam or clindamycin plus either cefuroxime or ceftriaxone, followed by oral amoxicillin/ clavulanate or clindamycin All patients recovered Conclusions: RPA, an aerobic/anaerobic polymicrobial infection, is increasing in frequency and is associated with increased recovery of GABHS in our patients Whether this rise in incidence is due to increased invasiveness of GABHS strains is to be determined
TL;DR: Although PCIS can follow a relapsing course, it does carry a favorable prognosis and the widespread use of reperfusion therapy and cardiac medications with anti-inflammatory properties may have reduced the incidence of PCIS.
Abstract: The postcardiac injury syndrome (PCIS) includes the postmyocardial infarction syndrome, the postcommissurotomy syndrome, and the postpericardiotomy syndrome. Dressler reported a series of patients who developed a pericarditis-like illness days to weeks after a myocardial infarction. Postcardiac injury syndrome also has been observed after cardiac surgery, percutaneous intervention, pacemaker implantation, and radiofrequency ablation. Postcardiac injury syndrome is characterized by pleuritic chest pain, low-grade fever, an abnormal chest x-ray, and the presence of exudative pericardial and/or pleural effusions. The pathophysiology of PCIS involves auto-antibodies that target antigens exposed after damage to cardiac tissue. The treatment of PCIS includes the use of nonsteroidal anti-inflammatory drugs and corticosteroids. Prophylactic use of corticosteroids before cardiac surgery has not been effective in preventing PCIS. The widespread use of reperfusion therapy and cardiac medications with anti-inflammatory properties may have reduced the incidence of PCIS. Although PCIS can follow a relapsing course, it does carry a favorable prognosis.
TL;DR: In this paper, a prospective randomized study of 100 patients with large-sized (> 20 mm) duodenal peptic perforation comparing omental plugging (study group) with omentopexy (control group) was carried out.
Abstract: Background: Due to friable margins and the moribund state of the patient, managing giant duodenal perforations (>20 mm in diameter) is a challenging task Methods: A prospective randomized study of 100 patients with large-sized (> 20 mm) duodenal peptic perforation comparing omental plugging (study group) with omentopexy (control group) was carried out Results: Size of the perforation varied between 20 to 30 mm No study group patients developed a postoperative perforation site leak, as compared with 6 patients in the control group Gastric outlet obstruction was significantly less at 6 weeks and 5 years in the study group as compared with the control group, and mortality was significantly less in the study group Conclusion: It was concluded that omental plugging was a safe and reliable method of treatment for large-sized duodenal peptic perforations
TL;DR: Primary care outpatients who report greater spirituality are more likely to report less depressive symptoms, and less insurance coverage and greater spirituality were associated with less reported depressive symptoms.
Abstract: Background: Although many studies have examined the relationship between religiosity and depressive symptoms in patient populations, there has been little work to understand and measure the effect of spirituality on depressive symptoms. Objective: The purpose of this study was to examine the association of spirituality and symptoms of depression in primary care outpatients. Methods: A cross-sectional analysis was performed of a dataset using 509 primary care outpatients who participated in an instrument validity study in the Kansas City (US) area. Patients were administered the Zung Depression Scale (ZDS) and the Spirituality Index of Well-Being (SIWB) in the waiting area before or after their appointment. Bivariate and multivariate analyses were performed to determine the relationship between the factors of interest and depressive symptoms. Results: In bivariate analyses, less insurance coverage (P < 0.01) and greater spirituality (P < 0.01) were associated with less reported depressive symptoms. In a model adjusted for covariates, spirituality (P < 0.01) remained independently associated with less symptoms. Conclusion: Primary care outpatients who report greater spirituality are more likely to report less depressive symptoms.
TL;DR: How spirituality represents both a potent resource and a source of struggle for people coping with medical illness is described and some practical suggestions for medical clinicians interested in addressing spirituality with their patients are concluded.
Abstract: Faced with medical illness, many people turn first to their faith for hope, comfort, strength, meaning, a sense of control, social support, and spiritual support. However, for a smaller but significant number of people, medical illnesses can signal the onset of a spiritual struggle that may presage declines in physical and mental health. In this paper, we describe how spirituality represents both a potent resource and a source of struggle for people coping with medical illness. We conclude with some practical suggestions for medical clinicians interested in addressing spirituality with their patients. When dealing with medical illness, people can draw upon a variety of spiritual coping resources. People can reframe a negative situation through a spiritual lens as potentially beneficial. For example, an illness can be attributed to God’s will or understood as an opportunity to grow spiritually. By seeking spiritual support from God, individuals may find peace and solace or gain a sense of intimacy with the sacred. Individuals can also draw upon the religious support from congregation members and clergy. Finally, when coping with medical illness, individuals may engage in profound spiritual transformations (eg, forgiveness, conversion) in which the sacred becomes a more central organizing value and priority in life. In a meta-analysis of 49 empirical studies including over 13,000 participants, spiritual coping resources were linked with important health benefits. While medical illness can strengthen an individual’s spiritual resolve, it can also shake an individual’s most basic assumptions about the world, including spiritual assumptions. Illnesses may elicit questions about the individual’s relationship with God, strain relationships with one’s religious community, or arouse internal doubts about the individual’s own spiritual values and beliefs. Such spiritual crises can produce more distress than even the physical symptoms of medical illnesses because they represent a threat to one’s sacred foundation. Empirical studies have shown that spiritual struggles, particularly when unresolved, can lead to declines in health, and even death. For example, in the previously cited metaanalysis, spiritual struggles were associated with various harmful consequences, such as perceived stress, PTSD symptoms, depression, anxiety, guilt, and suicidal tendencies. Furthermore, in a 2-year longitudinal study of religious coping among medically ill hospitalized elderly patients, spiritual struggles at baseline were predictive of greater risk of mortality. To address spirituality with patients effectively, it is important for healthcare providers to be open to the spiritual dimension. Because patients may be reluctant to raise their spiritual concerns, medical clinicians might broach the topic this way, “Spirituality often influences how people deal with illness. How, if at all, has your spirituality influenced how you have dealt with your medical condition?” Patients could respond to this open-ended question by discussing the poten-
TL;DR: Why to avoid using hypotonic parenteral fluids, risk factors for hyponatremic encephalopathy such as age, gender, and hypoxia, and the appropriate use of 3% sodium chloride are discussed.
Abstract: Dysnatremias are a common clinical entity that are often associated with poor outcomes This review takes a case study approach to understand how dysnatremias can result in devastating neurologic consequences Concrete guidelines are provided for prevention, early recognition and treatment along with a discussion of how urinary electrolytes and osmolality can be used to guide therapy Case studies in hyponatremic encephalopathy include the post-operative state, thiazide diuretics, extreme exercise and DDAVP use Reasons to avoid using hypotonic parenteral fluids, risk factors for hyponatremic encephalopathy such as age, gender, and hypoxia, and the appropriate use of 3% sodium chloride are discussed Case studies in hypernatremia include hypernatremia in the ICU setting and the emerging condition of breastfeeding-associated hypernatremia in infants
TL;DR: Based on the existing evidence, the optimal diet should emphasize fruits and vegetables, nuts, unsaturated oils, whole grains, and fish, while minimizing saturated fats, sodium, and red meats.
Abstract: Observational studies provide a wealth of important correlations between diet and disease. There is a clear pattern of dietary habits that is associated with reduced rates of a multitude of common illnesses, including heart attack, cancer, stroke, diabetes, and hypertension. In some cases, interventional studies have proven the benefits of dietary change; in others, there is insufficient evidence to prove causation. Based on the existing evidence, the optimal diet should emphasize fruits and vegetables, nuts, unsaturated oils, whole grains, and fish, while minimizing saturated fats (especially trans fats), sodium, and red meats. Its overall calorie content should be low enough to maintain a healthy weight.
TL;DR: Simultaneous and sustained response of hepatitis and pancreatitis to Saw palmetto abstinence with reoccurrence on reinstitution strongly favors drug effect.
Abstract: Saw palmetto is a frequently used botanical agent in benign prostatic enlargement (BPH). Although it has been reported to cause cholestatic hepatitis and many medical conditions, Saw palmetto has not been implicated in acute pancreatitis. We report a case of a probable Saw palmetto induced acute hepatitis and pancreatitis. A 55-year-old reformed alcoholic, sober for greater than 15 years, presented with severe non-radiating epigastric pain associated with nausea and vomiting. His only significant comorbidity is BPH for which he intermittently took Saw palmetto for about four years. Physical examination revealed normal vital signs, tender epigastrium without guarding or rebound tenderness. Cullen and Gray Turner signs were negative. Complete blood count and basic metabolic profile were normal. Additional laboratory values include a serum amylase: 2,152 mmol/L, lipase: 39,346 mmol/L, serum triglyceride: 38 mmol/L, AST: 1265, ALT: 1232 and alkaline phosphatase was 185. Abdominal ultrasound and magnetic resonance cholangiography revealed sludge without stones. A hepatic indole diacetic acid scan was negative. Patient responded clinically and biochemically to withdrawal of Saw palmetto. Two similar episodes of improvements followed by recurrence were noted with discontinuations and reinstitution of Saw Palmetto. Simultaneous and sustained response of hepatitis and pancreatitis to Saw palmetto abstinence with reoccurrence on reinstitution strongly favors drug effect. "Natural" medicinal preparations are therefore not necessarily safe and the importance of detailed medication history (including "supplements") cannot be over emphasized.
TL;DR: There is evidence that taking ciprofloxacin or levofloxacIn, assuming that there are not any concurrent risk factors, will not cause a significant prolongation in the QT interval, and this also held true for the longest QTc interval.
Abstract: Background The widespread use of the fluoroquinolones has raised the question of the cardiac safety of these medications. This widespread use of this class of antibiotics has displayed their safety profile, which is actually more favorable than many other drug classes. The cardiac toxicity issue at the center of this discussion is the prolongation of the QT interval leading to torsade de pointes. Ciprofloxacin and levofloxacin, two of the more commonly used fluoroquinolones, are considered less likely than other fluoroquinolones to prolong the QT interval. The authors set out to evaluate the effect on the QT interval of patients after administration of ciprofloxacin and levofloxacin. Methods A prospective evaluation of 38 consecutive patients evaluated by the infectious disease service and receiving either ciprofloxacin or levofloxacin was undertaken. Twelve-lead electrocardiograms were obtained at baseline and at least 48 hours after the first dose of the antibiotic was administered. Both the longest QT interval and the mean QT interval were evaluated. To account for variations in heart rate, the corrected QT interval was calculated by using Bazett's formula (QTc = QT(square root of) R-R). Statistical analysis was undertaken to assess for the presence of a change after the administration of the antibiotic. Results Thirty-eight patients (mean age, 65 +/- 19 years), 23 women and 15 men, were studied. There was a small but significant increase in the longest QTc intervals over baseline in patients receiving levofloxacin; there was no significant change in the mean QTc interval. However, one patient who received levofloxacin was, statistically, an outlier and, on retrospective analysis, had demonstrated severe electrolyte disturbances at the time of the study. When this patient was excluded, the increase in the longest QTc interval was not significant. Patients receiving ciprofloxacin did not demonstrate any significant change in the longest QTc interval or mean QTc interval. Conclusions Neither levofloxacin nor ciprofloxacin significantly prolonged the mean QTc interval over baseline. When electrolyte deficiencies in one of the patients evaluated were taken into account, this also held true for the longest QTc interval. There is, therefore, evidence that taking ciprofloxacin or levofloxacin, assuming that there are not any concurrent risk factors, will not cause a significant prolongation in the QT interval.
TL;DR: The overall prognosis of rectal MALT lymphoma appears favorable; however, long-term follow-up data is lacking and periodic clinical monitoring should be done in these patients.
Abstract: The primary extranodal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is a distinct clinical pathologic entity that develops in diverse anatomic locations such as the stomach, salivary gland, thyroid, lung, and breast; however, colorectal involvement is rare. To the best of our knowledge, only 30 cases of primary rectal MALT lymphoma have been published in the English language literature, mostly from Japan. A single case has been reported from the US before this report. The most common symptoms ranged from asymptomatic to occult or gross gastrointestinal bleeding. Simultaneous involvement of the cecum or colon was seen in 20% of the patients. Ninety percent of the patients were classified as low grade, Stage 1 at the time of diagnosis. Polypoid lesions were 10-fold more common than ulcerative lesions. Seven patients were reported to have H pylori in the stomach. The majority of the patients underwent surgical or endoscopic resection as a cure; however, controversy exists with regards to antibiotic treatment or observation alone because of unknown etiopathogenesis. Infection with microorganisms other than H pylori has been postulated in the development of rectal MALT lymphoma; however, this hypothesis remains unproven. The overall prognosis of rectal MALT lymphoma appears favorable; however, long-term follow-up data is lacking. Therefore, periodic clinical monitoring should be done in these patients.
TL;DR: Two infants, the products of home deliveries, who did not receive vitamin K at birth who developed ICH at 5 weeks of age are presented, illustrating that hemorrhagic disease of the newborn can occur when prophylactic vitamin K is not administered and that it can have devastating consequences.
Abstract: In infants, intracerebral hemorrhage (ICH) is most likely the result of trauma or disturbances of coagulation function. Routine and standard care of the newborn includes the administration of vitamin K to prevent hemorrhagic disease of the newborn. We present two infants, the products of home deliveries, who did not receive vitamin K at birth. Both infants developed ICH at 5 weeks of age and presented with signs and symptoms of increased IC pressure. In both cases, recombinant factor VIIa was administered to correct coagulation function and allow immediate surgical intervention which included craniotomy and hematoma evacuation in one patient and placement of a ventriculostomy in the other to treat increased IC pressure. Despite this therapy, both infants were left with severe neurologic sequelae. These two cases illustrate that hemorrhagic disease of the newborn can occur when prophylactic vitamin K is not administered and that it can have devastating consequences. Given these issues, the routine administration of vitamin K to all infants is mandatory and should not be considered optional.